Cost-effectiveness analysis of integrated care for people with HIV, chronic mental illness and substance abuse disorders.

BACKGROUND: Triply diagnosed patients, who live with HIV and diagnosed mental health and substance abuse disorders, account for at least 13% of all HIV patients. This vulnerable population has substantial gaps in their care, attributable in part to the need for treatment for three illnesses from three types of providers. AIMS OF THE STUDY: The HIV/AIDS Treatment Adherence, Health Outcomes and Cost study (HIV Cost Study) sought to evaluate the cost-effectiveness of integrated HIV primary care, mental health, and substance abuse services among triply diagnosed patients. The analysis was conducted from a health sector budget perspective. METHODS: Patients from four sites were randomly assigned to intervention group (n=232) or control group (n=199) that received care-as-usual. Health service costs were measured at baseline and three, six, nine and 12 months and included hospital stays, emergency room visits, outpatient visits, residential treatment, formal long-term care, case management, and both prescribed and over-the-counter medications. Costs for each service were the product of self-reported data on utilization and unit costs based on national data (2002 dollars). Quality of life was measured at baseline and six and 12 months using the SF-6D, as well as the SF-36 physical composite score (PCS) and mental composite score (MCS). RESULTS: During the 12 months of the trial, total average monthly cost of health services for the intervention group decreased from USD 3235 to USD 3052 and for the control group decreased from USD 3556 to USD 3271, but the decreases were not significant. For both groups, the percentage attributable to hospital care decreased significantly. There were no significant differences in annual cost of health services, SF-6D, PCS or MCS between the intervention and control group. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The results of this randomized controlled trial did not demonstrate that the integrated interventions significantly affected the health service costs or quality of life of triply diagnosed patients. Professionals could pursue coordination or integration of care guided by the evidence that it does not increase the cost of care. The results do not however, provide an imperative to introduce multi-disciplinary care teams, adherence counseling, or personalized nursing services as implemented in this study. IMPLICATIONS FOR HEALTH POLICIES: There is not enough evidence to either limit continued exploration of integration of care for triply diagnosed patients or adopt policies to encourage it, such as financial reimbursement, grants regulation or licensing. IMPLICATIONS FOR FURTHER RESEARCH: Future trials with interventions with lower baseline levels of integration, longer duration and larger sample sizes may show improvement or slow the decline in quality of life. Future researchers should collect comprehensive cost data, because significant decreases in the cost of hospital care did not necessarily lead to significant decreases in the total cost of health services.

Impact of HIV/AIDS education on health care provider practice: results from nine grantees of the Special Projects of National Significance Program.

The study assessed the impact of health care provider HIV/AIDS education and training on patient care from nine Special Projects of National Significance. Telephone interviews were conducted with 218 health care providers within 8 months, on average, following completion of training. Respondents provided examples of how the SPNS trainings affected their provision of patient/client care. Transcribed comments reflecting change in patient/client care were classified by independent coders under 1 of 10 broad practice change categories. Eighty-two percent of the trainees identified at least one instance of change in patient/client care as a function of their training experience. Self-reported findings included changes in the number/types of patients seen, interpersonal interactions with patients/clients, HIV testing and counseling practices, patient/family education, infection control, advocacy, referrals and collaboration, documentation, and other service changes.

The effect of mental illness, substance use, and treatment for depression on the initiation of highly active antiretroviral therapy among HIV-infected individuals.

Information regarding the prevalence of mental illness and substance use among HIV-infected patients and the effect of these problems on HIV treatment is needed. We conducted an observational study of patients in the University of Washington (UW) HIV Cohort to determine prevalence rates for mental illness and substance use. Cox regression analyses were used to examine the relationship between mental illness and substance use, pharmacologic treatment for depression/anxiety, and initiation of highly active antiretroviral therapy (HAART) within 9 months of becoming eligible for HAART. Among 1774 patients in the UW HIV cohort during 2004, 63% had a mental illness (including mood, anxiety, psychotic, or personality disorders), 45% had a substance use disorder, and 38% had both. There were 278 patients who met criteria for HAART eligibility. After controlling for other factors, patients with depression and/or anxiety were significantly less likely to initiate HAART compared with patients without a mental illness (hazard ratio [HR] 0.4, p = 0.02). However, patients with depression/anxiety who received antidepressant/antianxiety medications were equally likely to initiate HAART as patients without a mental illness (HR 0.9, p = 0.5). We found that patients with mental illness or substance use disorders receive HAART at lower CD4+ cell counts and higher HIV-1 RNA levels than patients without these disorders. However, HAART initiation among patients who receive treatment for depression/anxiety is associated with no delay. Screening for these disorders in primary care settings and access to appropriate treatment are increasingly important components of providing care to HIV-infected patients.